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 Expert Review Examination of the Shoulder
Mickhaiel Barrow 1 Thomas W Hamilton2 and Parminder J Singh3
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The Journal of Clinical Examination 2011 (11): 44-56
Abstract
Shoulder pain is the second most common musculoskeletal condition seen in primary care. Specialists, general
practitioners and medical students should be able to perform a thorough examination of the shoulder. This article
describes techniques for shoulder examination in a simple ‘look, feel, move’ format and considers each method
from a critical point of view. It is based on a review of the literature, textbook accounts and the author’s personal
experience. Word count: 6241.
Key Words: shoulder, examination, impingement, pain, movement.
Address for correspondence: [email protected]
Author affiliations: *1 Foundation Year 1 Doctor, High Wycombe Hospital. *2 Academic Foundation Year
Doctor, John Radcliffe Hospital, Oxford. *3. Consultant Trauma and Orthopaedic Surgeon South West London
Elective Orthopaedic Centre, Epsom, Surrey.
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Introduction
The glenohumeral or ‘shoulder’ joint is formed by
the articulation of the glenoid fossa of the scapula
and the head of the humerus. It has an open ball
and socket structure and is held away from the
chest wall by the clavicle as shown in Figure 1a. It is
stabilised by the glenoid labrum and the intrinsic
ligaments (glenohumeral and coracohumeral
ligaments) within the fibrous capsule and by the
tone of the rotator cuff muscles (supraspinatus,
infraspinautus, teres minor and subscapularis) – see
Figure 1b.
Figure 1b Anatomy of shoulder joint
The acromioclavicular (AC) joint is formed from the
acromion of the scapula and the lateral tip of the
clavicle. It is stabilised by the coracoclavicular,
acromioclavicular and coracoacromial ligaments.
The AC joint may become dislocated or subluxed by
trauma.
Figure 1a Bony and soft tissue of shoulder joint
Other clinically important structures include the
tendons of the rotator cuff muscles which pass
between moving bones and may tear or become
inflamed. Finally, the nerves of the brachial plexus
with the accompanying brachial artery and vein
44 emerge from the axilla, just inferior to the
glenohumeral joint and can be damaged as a result
of shoulder dislocation, direct trauma or surgery.
Shoulder pathology is common especially in middle
and old age. The differential diagnosis for pain and
reduced range of movement in the shoulder is long
but there are only a few common causes. These
will be the focus of this article and they are listed in
Table 1.
Subacromial impingement
Rotator cuff tears
Frozen Shoulder
Instability of the glenohumeral joint
Dislocation of the shoulder
Osteoarthritis of the glenohumeral joint
Osteoarthritis of the acromioclavicular joint
Rupture of the long head of the biceps tendon
Referred pain from the cervical spine
Table 1 Common Disorders of the Shoulder
Impingement is a syndrome of shoulder pain and
reduced range of movement which usually occurs in
patients over forty years old. Patients typically
complain of pain during abduction from 70-120
degrees.
Repetitive microtrauma to the
supraspinatus tendon of the rotator cuff leads to
degeneration of the hypovascular distal portion of
the tendon and is more likely with increasing age.
Swelling of rotator cuff leads to impingement
beneath the acromion and coracoacromial ligament
especially when the arm is elevated and internally
rotated. This causes pain associated with lifting the
arm over one’s head. Later in the life bony changes
of the acromion occur which further contributes to
wear of the rotor cuff and predisposes to rotator cuff
tears.
Rotator cuff tears typically occur in young patients
following trauma or spontaneously in older patients
secondary to degenerative changes. Tears in
supraspinatus cause weakness in initiating
abduction and this movement may be painful if the
tear impinges on adjacent structures.
Pain and limitation of movement in all directions (in
the presence of a normal radiograph) is
characteristic of adhesive capsulitis - also known as
frozen shoulder. Rotation is especially affected and
pain may be severe. In this condition, minor trauma
or prolonged immobilization is believed to initiate
low grade inflammation in the rotator interval
(capsuloligamentous
structures
between
supraspinatus and subscapularis) which leads to
scarring and contraction.
Laxity is defined as looseness of the soft tissues
around the shoulder joint. It is important to note that
although joint laxity predisposes to instability, a lax
joint can be stable so positive laxity tests should not
be interpreted as instability [1,2]. See the section on
‘Special Tests’ for tests of joint laxity. Instability
occurs when supportive structures around the
shoulder joint fail to keep the humeral head
correctly positioned in the glenoid fossa during
movement. Dislocation occurs if there is complete
separation of the humeral head from the glenoid
fossa while subluxation is defined as symptomatic
translational movement without complete separation
[3]. If you suspect joint laxity, potential causes should
be considered (eg. Ehlers-Danlos syndrome).
Dislocation of the shoulder joint should always be
considered following trauma. Anterior dislocation is
the most common, and typically follows a fall forcing
external rotation of the shoulder or a fall backwards
onto an extended arm. These forces drive the
humeral head anterior to the glenoid fossa and
inferior to the coracoid process. Patients are in
severe pain and do not permit the examiner to move
the shoulder joint. Axillary nerve damage is a
common complication and should be tested by
examining the lateral aspect of the arm (commonly
known as the ‘regimental badge’) for a loss of
sensation. Chronic damage to this nerve results in
wasting of the deltoid muscle. Posterior dislocation
is less common and is associated with a direct blow
to the anterior aspect of the shoulder, electric shock
and seizures. Patients present with their arm locked
in medial rotation - a scapular lateral and axillary
radiograph is needed to make the diagnosis. Inferior
dislocation (or ‘luxatio erecta’) is very uncommon
and caused by a downwards axial force applied to
the shoulder while the arm is fully abducted.
Associated injuries include damage to brachial
plexus, axilliary artery and fractures of the acromion,
clavicle and greater tuberosity.
Glenohumeral joint osteoarthritis is a relatively
uncommon cause of shoulder pain. It is usually
idiopathic but may follow trauma or dislocation of
the shoulder. It is more common in patients over
age 60 years and in women. It presents with
gradual onset anterior shoulder pain and stiffness
that is aggravated by activity and relieved by rest.
45 Creptius may be elicited on movement of the joint.
Multiple joint involvement should always prompt the
examiner to consider rheumatoid arthritis as a
potential cause. Clinical examination may be unable
to distinguish osteoarthritis from other causes of
shoulder pain and a plain radiograph of the shoulder
is needed for diagnosis.
Osteoarthritis may also affect the acromioclavicular
joint resulting in pain. Patients complain of stiffness
and pain over the acromioclavicular joint especially
when the arm is adducted across the chest (scarf
test – see below) and in the end-range of flexion
and
abduction.
On
examination,
the
acromioclavicular joint may appear prominent,
swollen and tender on palpation. Initial treatment is
physiotherapy and steroid injections. Surgical
excision of the distal end of the clavicle may be
required in advanced disease.
Rupture of the long head of the biceps tendon may
occur following chronic inflammation or
impingement in patients aged between forty and
sixty years old. Traumatic rupture may be seen in
younger patients. Some patients complain of a
sharp, acute shoulder pain which may be
accompanied by a snapping sound while others
may simply experience recurrent pain during
repetitive activities. On examination, there is a
visible bulge on the anterior aspect of the arm (the
‘Popeye’ sign) during flexion of the elbow and
tenderness in the bicipital groove.
Finally, in patients presenting with shoulder pain,
always consider the neck as the site of referred
pain. As described below, the ‘Epaulette Sign’ can
be use to differentiate localized pathology from
referred neck pain. A full discussion of the causes
of referred neck pain is beyond the scope of this
article, but osteoarthritis of facet joints and
degenerative disk disease are two of the most
common pathologies. A full neurological
examination of the upper limb is required to exclude
neural damage if referred neck pain is suspected.
Literature Search
The following textbooks of clinical examination were
searched:
Evidenced Based Physical Diagnosis [11]
The PubMed database was searched using the
terms ‘shoulder AND examination’. Results were
entered into the clinical queries filter under
‘diagnosis’ and ‘narrow-specific search’. Additional
searches were conducted for special orthopaedic
tests including search terms such as ‘supraspinatus
test’,
‘Neer’Iimpingement
test’,
‘Hawkin’s
impingement sign’, ‘Yegason’s sign’, ‘external
rotator lag sign’, ‘drop sign’, ‘belly press test’, ‘lift off
test’, ‘sulcus test’, ‘apprehension test’, ‘Jobe’s
relocation test’, ‘cross arm adduction stress test’,
‘active compression test’, ‘Kim test’, and ‘biceps
load test II’. The Cochrane Library was also
searched using the keywords ‘shoulder pain’,
‘shoulder impingement syndrome’ and ‘shoulder
joint’.
Beginning the Examination
Begin by introducing yourself, explain what you
intend to do and take informed consent. The
examination is best performed with the patient
standing upright with good exposure of the
shoulders, arms and neck – see Figure 2. This will
allow examination of the anterior, posterior and
lateral aspects of both shoulders. Men should be
asked to remove their shirts and women may be
examined with a gown tied around their backs or
whilst wearing only a bra. The patient should be
comfortable and relaxed and you should enquire
about pain before proceeding with the examination.
Figure 2. Correct exposure for examination of
the shoulder joint, women may be examined
with a gown tied around their backs or whilst
wearing only a bra.
Inspect (‘Look’)
Global Inspection
Begin by looking at the whole patient. Always
compare both sides of the body and look at the
patient from the front, the back and the side – see
Figure 3. Look for signs of disease in other systems
which may be relevant to shoulder pathology. Once
the global inspection is complete move on to look
46 more closely at the shoulders. As a memory aid,
consider structures that are related to the skin, soft
tissue and bones at each stage in the examination.
Skin
Look for bruising or scars (including incisions for
arthroscopic surgery) that might suggest trauma or
previous surgery. Inspect the skin for areas of
erythema and check the axillae for sinuses both of
which may be caused by an underlying infection.
Soft Tissue
Compare the curvature of both shoulders and look
for asymmetry. Increased angularity or ‘squaring’ of
the deltoid can occur as a result of deltoid wasting
following axillary nerve damage in patients with a
history of anterior shoulder dislocation. Similarly,
inspect the muscle bulk above and below the spine
of the scapula (supraspinatus and infraspinatus
respectively). Wasting appears as hollow grooves
and typically occurs 2-3 weeks after tears in the
rotator cuff.
Figure 3
aspects.
Inspect the shoulder joint from all
Advanced rotator cuff disease can also be
associated with tears in the long head of biceps
tendon, which can be seen as a visible bulge when
the patient flexes his elbow (Popeye sign).
Bone
Acute anterior dislocation of the humeral head is
usually very painful and associated with a history of
trauma. The arm is usually held at the side slightly
away from the body with the forearm turned
outward.
You may see decreased shoulder
roundness and a bump in front of the shoulder
caused by the dislocated humeral head but swelling
may obscure these signs.
A prominent bump at the distal end of the clavicle
may indicate acromioclavicular joint subluxation. A
painless bump in the middle of the clavicle may
indicate an old malunited clavicle fracture.
47 When inspecting from behind, look at position of the
scapula, which may be abnormal in neuromuscular
disorders or in patients who have injured of the long
thoracic nerve – this typically causes ‘winging’ of the
scapula where the medial border appears to be
lifted off the back like a wing.
The Epaulette Sign
Before palpation, ask whether there are any tender
areas. As pain may be referred from the cervical
spine, the Epaulette Sign is useful in differentiating
this from localised shoulder pain. An epaulette,
derived from the French word meaning ‘little
shoulder’, is an ornamental shoulder piece worn by
soldiers as an insignia or an indication of rank.
When asked to point to the pain, a patient with
localised shoulder pain will point to a specific area
while someone with neck pain will rub the area
typically covered by an epaulette. See figure 4.
Palpate (‘Feel’)
Skin and Neurovascular Status
Begin palpation by assessing the temperature of
each shoulder using the dorsal surface of your
hand. The neurovascular status of the arm should
be assessed because nerves and vessels may be
damaged by shoulder pathology especially acute
dislocation. However, this does not form part of the
routine examination of the shoulder except in major
trauma or unless acute dislocation is suspected so it
is included in the section ‘Completing the
Examination’ at the end of this article.
Soft Tissue
Palpate the trapezius muscle from behind. Ask the
patient if it is tender and look at the face for signs of
pain. Tenderness in the trapezius is common in
referred neck pain.
Bone
Palpate along the clavicle from the sternoclavicular
joint to the acromioclavicular joint and then the
shoulder. Ask the patient if it is tender and look at
the face for signs of pain. Tenderness over the
greater tuberosity may indicate rotator cuff
pathology
and
tenderness
over
the
acromioclavicular joint is strongly indicative of
pathology in the acromioclavicular joint.
Manipulate (‘Move’)
Active Movements
Figure 4 Pain may be referred from the cervical
spine, the Epaulette Sign is useful in
differentiating this from localised shoulder pain.
An epaulette, derived from the French word
meaning ‘little shoulder’, is an ornamental shoulder
piece worn by soldiers as an insignia or an
indication of rank.
Apley Scratch Test
Use the ‘Apley Scratch Test’ (see Figure 6) for a
quick initial assessment. Stand behind the patient
and ask them to scratch over the opposite scapula
by reaching over the unaffected shoulder, then by
reaching behind the neck and finally by moving their
hand behind their back on the same side. Normal
ranges of shoulder movement are listed in Table 2.
Movement
Flexion
Extension
Abduction
External rotation
Internal rotation
Range
180°
50°
180°
70°
50°
Table 2 Range of Movements
48 Figure 7a Active shoulder flexion.
Figure 5 Assess the temperature of the
shoulder using the dorsum of the hand (a). From
behind palpate the trapezius muscle and look at
the face for signs of pain (b). Palpate the bony
structues methodically (c).
Assess Individual Movements
Individual movements of the shoulder can then be
tested by asking the patient to copy you as you
move your arms.
Figure 6 The Apley Scratch Test
Figure 7b Active shoulder extension.
Flexion and Extension
Start by standing in-front of the patient and prompt
them to move into full flexion and then full
extension.
Abduction and Detection of a Painful Arc
Then test abduction with the arms in the plane of
the scapula (about 30° forwards) by lifting the arms
slowly above the head as shown in Figure 8. The
movement should be performed slowly and the
patient should be asked to indicate if they feel any
49 pain – known as ‘painful arc’. Then repeat this
movement whilst observing the patient from behind
to assess the scapulohumeral rhythm. For the first
90° of abduction, there should be little movement at
the scapula. Beyond 90° the scapula should rotate
with the humerus at the same rate to facilitate
abduction. Abnormal scapulohumeral rhythm could
indicate damage to the scapula stabilizers or
involuntary adaptation to avoid pain. Pain during
abduction is known as a painful arc and it should be
further characterised in terms of the point of
maximal pain. Pain from 60-120° is typical of
impingement syndrome whereas weakness
especially in the absence of pain makes a rotator
cuff tear more likely. Pain in the end-range of
flexion and abduction (160-180°) is indicative of
acromioclavicular joint pathology.
Move the forearm away from the midline and then
back towards the midline.
Figure 9. Active external (a) and internal (b)
rotation of the shoulder.
Passive Movements
With one hand over the shoulder joint, test passive
flexion, extension, abduction and external rotation.
For the sake of comfort, flexion can be tested with
the patient seated and the examiner standing
behind or adjacent to the patient as shown in Figure
10. Extension is best tested with both patient and
examiner standing, with one hand over the shoulder
joint and the other hand just above the elbow.
Similarly, passive internal and external rotation are
best tested with one hand stabilizing the elbow and
the other examiner’s hand at the patient’s wrist as
shown.
Completing the Examination
Complete the examination by thanking the patient,
helping them redress and washing your hands.
Figure 8 Active shoulder abduction. The arms
should be in the plane of the scapula (about 30°
flexion).
The special tests listed in Table 3 and described
below do not form part of the basic examination of
the shoulder but they may give additional
information when performed by examiners who are
competent in the required techniques and their
interpretation. Specialists may include some of them
in their routine examination of the shoulder.
Internal and External Rotation
Next test external and internal rotation by fully
adducting the arm so the elbows are against the
lateral chest wall and flexing the elbow to 90°.
A full assessment of the shoulder includes
assessment of the neurovascular status of the arm.
Check the radial pulse and capillary refill time and
then test sensation. Formal examination of
50 dermatomal sensation should be carried out
including testing sensation over the ‘regimental
badge’ area supplied by the axillary nerve if an
anterior glenohumeral joint dislocation is suspected.
In medical school OSCEs and routine practice such
a thorough assessment is usually not required and
the extent of the examination should be tailored to
the situation. See Examination of the Peripheral
Nerves [4] and Examination of the Peripheral Arterial
System[5] for a full account of how to perform these
examinations
Hawkin’s Impingement Sign
Standing adjacent to the seated patient, the
examiner holds the patient’s arm with one hand and
lifts it into 90° of forward flexion. The other hand
grasps the patiens forearm and flexes the elbow to
90°. In this position, the shoulder is rotated
internally by pushing the forearm towards the
patient’s midline [6]. This forces the greater
tuberosity against the coracoacromial ligament
causing pain in impingement. Sensitivities and
specificities for this test range from 72-92% and 2644% respectively [7,8]. See Evidence Box 1.
Tests for Rotator Cuff Pathology
Supraspinatus Test / Jobe’s Test / Empty Can
Test
This test is for supraspinatus integrity. Ask the
patient to elevate arms in the plane of the scapula
(90° forward) with full extension of the elbows. Arms
are pronated so thumbs face downwards to the floor
and then the examiner pushes down on the arms
while the patient attempts to resist. Inability to
maintain shoulder elevation is a sign of
supraspinatus weakness.
External Rotation Lag Sign (ERLS)
With the patient’s back to the examiner, the elbow is
passively flexed to 90° and the shoulder is held at
20° of elevation in the scapular plane by supporting
the arm. The shoulder is maximally externally
rotated minus 5° to avoid elastic recoil, and then
released at the wrist. An angular drop indicates a
failure in the integrity of the infraspinatus tendon [3].
Figure 10. Assess passive range of movement
in the shoulder.
Special Tests
Tests for Impingement Syndrome
Neer Impingement Sign
With the examiner standing behind the seated
patient, one hand is placed over the patient’s
scapula to prevent it from moving during the test.
The examiner then grasps the patient’s forearm with
his other hand and draws the arm into forward
elevation [6]. This action compresses the greater
tuberosity against the anterior acromion, eliciting
pain in impingement syndromes. This test has a 7589% sensitivity and 32-48% specificity [7]. See
Evidence Box 1.
Lift-Off Test and Lift-Off ‘Lag Sign’
Described by Gerber and Krushell in 1991 [20], the
Lift-Off test can also be used to diagnose an
isolated subscapularis tendon rupture. The patient
actively places his hand behind his back by
internally rotating his shoulder and flexing the
elbow. In this position, the patient is then asked to
attempt lifting the dorsum of his hand away from his
back. If there is a rupture in subscapularis, the
patient would be unable to ‘lift-off’ his hand. In 1996,
Gerber et al. developed the lift-off test (‘lag sign’) [3]
as another means of detecting isolated rupture of
subscapularis. In this test, the patient’s arm was
passively placed in the same position as above and
then the examiner’s hand was removed. Patients
with subscapularis rotator cuff tears would not be
able to maintain maximal internal rotation.
51 Tests for Impingement Syndrome
Neer Impingement Sign
Hawkins Impingement Sign
Tests for Rotator Cuff Pathology
Supraspinatus Test / Jobe’s Test / Empty Can
Test
External rotation lag sign (ERLS)
Lift-Off Test and the Lift-Off Lag Sign
Belly press test
Drop sign / Hornblower’s Sign
Tests for Biceps Tendon Pathology
Speed’s Test
Yeagson’s sign
Tests for Instability, Laxity and Labral
Pathology
Anterior Pathology
Apprehension Test (Anterior Instability)
Jobe’s Relocation Test
Load and Shift Test
Posterior Pathology
The Kim Test (Posterior Labral Tears)
Jerk Test for Posterior Instability
Superior Pathology
Active Compression Test (O’Brien’s test)
Inferior Pathology
Sulcus Sign (Joint Laxity)
Tests for Pathology of the Glenoid Labrum
The Biceps Load Test II
Tests for Hyperlaxity
Beighton’s Hyperlaxity Score
Tests for Acromioclavicular Joint Pathology
Scarf Test / Cross Arm Adduction Stress Test
Active Compression Test (O'Brien's test)
Table 3 Special tests.
Belly Press Test
This tests aims to detect specific pathology in
subscapularis [1]. It is performed by asking the
patient to press his abdomen with the flat of his
hand holding it in that position. If internal rotation is
impaired, his elbow will move backward, moving
behind the trunk. In addition, the patient will attempt
to maintain the position by extending the shoulder
or flexing the wrist rather than internally rotating the
arm.
Drop Sign / Hornblower’s Sign
With the patient and examiner in the same position
as the ERLS test the affected arm is passively
elevated to 90° and fully externally rotated with the
elbow flexed to 90°. In this position, TERES MINOR
is principally responsible for maintaining external
rotation. Releasing the wrist while supporting the
arm will cause an angular drop if teres minor or its
tendon is compromised.
Tests for Biceps Tendon Pathology
Speed’s Test
Speed’s test is performed with the patient in a
standing or sitting position with the examiner
standing to the side of the patient. The patient’s arm
is forwardly flexed to 60-90° with the elbow fully
extended and the hand fully supinated. The
examiner pushes downwards at the wrist. A positive
result is obtained if this force produces pain in the
bicipital groove or the anterior shoulder. Reported
sensitivities and specificities are 90% and 14%
respectively [13].
Yegason’s Sign
Yegason’s Sign is used to detect bicipital tendonitis.
The examiner stands in front of the patient and
flexes the elbow while the patient’s arm remains in a
neutral position. The wrist is then pronated by
grasping the hand and the forearm of the patient.
From this starting position, the test is then
performed by asking the patient to supinate his wrist
against resistance. With the elbow flexed, the
biceps muscle is one of the main supinators of the
forearm, this action applies tension on the biceps
muscle and pain in the bicipital groove is indicative
of bicipital tendonitis. This test has a 37% sensitivity
and a 82% specificity [7]. If bicipital tendonitis is
found, further tests should be conducted for rotator
cuff injury associated with subacromial impingement
which is often the underlying pathology. Also note
that this test is of limited use in the presence of
partial or complete rupture of the supinator muscle
or tendons.
Tests for Instability, Laxity and Labral Pathology
Anterior Pathology
‘Apprehension Test’ (Anterior Instability)
This test is best performed with the patient lying
supine to stabilise the scapula. The patient’s arm is
passively abducted to 90° and flexed at the elbow to
52 90°. Grasping the patient’s forearm, the shoulder
joint is then gently externally rotated by pulling the
forearm towards the examiner. While doing this, the
examiner’s other hand is placed over the posterior
aspect of the patient’s humeral head, and pressure
is gently applied in an anterior direction. If the
patient becomes apprehensive, and wants to stop
the test because he feels that his shoulder joint is
about to be dislocated by further applied pressure or
movement, the test has a positive result.
After the Apprehension Test the examiner should go
on to perform Jobe’s Relocation Test.
Jobe’s Relocation Test
The same procedure is used as above for the
‘Apprehension Test’, but the examiner’s hand is
placed on the anterior aspect of the shoulder to
stabilise the glenohumeral joint. If this removes the
patient’s apprehension, the test has a positive
result. One review [1] reported a sensitivity of 68%
and a specificity of 100% for this test. Importantly,
the relief of apprehension rather than pain should
be used as the diagnostic criterion as it was found
that pain relief occurred in several different
disorders when a posteriorly directed force was
applied.
Load and Shift Test
The Load and Shift Test is performed with the
patient seated, with his arm in a neutral position at
the side, and the examiner positioned behind the
patient. The examiner places one hand over the
patient’s scapula to stabilise it and the other hand is
used to grasp the humeral head. A loading force is
applied by the examiner to ensure that the humeral
head lies centrally within the glenoid fossa. From
this ‘loaded position’, a translational force is applied
anteriorly and then posteriorly and the distance
moved can be used to quantify the degree of laxity.
For example, 0-1cm, mild laxity; 1-2cm or translates
to glenoid rim, moderate laxity; >2cm translation or
over the rim of the glenoid, severe laxity. Both
shoulders should be compared. The test can then
be repeated with the patient in a supine position and
the examiner at the side of the bed. The arm is held
instead, and positioned into 20° of abduction and
forward flexion. The humeral head is centred with a
loading force and then shifting forces applied
anteriorly and posteriorly. By varying the amount of
abduction, the examiner can selectively target and
test individual ligaments. With 0-60° of abduction,
the superior glenohumeral ligament and
coracohumeral ligament are tested. With 60-90° of
abduction, the middle glenohumeral ligament is
tested, and the inferior glenohumeral ligament can
be examined using more than 90° of abduction [14].
Posterior Pathology
The Kim Test (Posterior Labral Tears)
This test is performed with the patient sitting with his
arm in 90° of abduction and his elbow flexed to 90°.
The examiner supports the patient’s elbow and
lateral forearm. An axial loading force and 45°
upward diagonal elevation is applied to the distal
arm, while inferior and posterior force is applied to
the proximal arm. Sudden onset pain in the
posterior shoulder is a positive test. It is important,
while performing the test, to apply firm axial
compression force to the glenoid surface by the
humeral head, and sitting the patient against the
back of a chair is useful for counter-support [15]. A
review of this test [8] believed the Kim test to be
virtually diagnostic for posteroinferior labral lesions,
having sensitivities and specificities of 80% and
94% respectively.
Jerk Test for Posterior Instability
The Jerk Test can also be used to detect posterior
labral tears and instability. This test is performed by
placing the patient’s humerus in a dislocated or
subluxed position at the start of the test and if the
joint is relocated during the test, a positive result is
obtained. The patient either sits or stands and the
examiner stands to the affected side, placing one of
his hands on the patient’s elbow and the other over
the scapula for stabilisation. In order to sublux the
humerus, the arm is flexed to 90° and internally
rotated with elbow also flexed to 90°. The examiner
pushes posteriorly at the elbow and maintains the
pressure. From this starting position, the arm is
slowly abducted while maintaining the humerus
parallel to the floor. If there is laxity, this manoeuvre
will relocate the humeral head into the glenoid
fossa, while will be felt as a clunk or a jerk with the
stabilising hand. In comparison to the Kim test, the
Jerk test has a 73% sensitivity and 98% sensitivity
for detecting posteroinferior labral lesions [15,16].
Superior Pathology
Active Compression Test (O’Briens Test)
Please see following section below
Acriomioclavicular Joint Pathology.
on
53 Inferior
Sulcus Test (Joint Laxity)
The Sulcus test is performed with the patient sitting
or standing and facing the examiner. The patient’s
arm is allowed to relax at his side in a neutral
position. By holding the arm or forearm, the
examiner gently applies a downward traction force
and observes whether a groove is created between
the humeral head and the acromion of the affected
shoulder, indicating laxity. However, a recent review
[3] reported the sensitivity and specificity as 31% and
89% respectively, suggesting that it was a poor test
at detecting or confirming laxity.
Tests for Pathology of the Glenoid Labrum
The Biceps Load Test II
A SLAP (Superior Labrum Anterior and Posterior)
lesion is a labral detachment which originates
posterior to the long head of biceps insertion and
extends anteriorly [18]. With the patient lying supine
and the affected shoulder at the edge of the bed,
the examiner grasps the patient’s wrist and elbow.
The arm is elevated to 120° and maximally
externally rotated with the elbow in 90° of flexion
and the forearm supinated. While resistance is
applied, the patient is asked to flex the elbow. A
positive result is pain experienced during resisted
elbow flexion. No pain, or no change in pre-existing
pain, is considered to be a negative result. A
sensitivity and specificity of 89.7% and 96.9% has
been reported [19]. Review of the biceps load test II
found that it was one of the most promising tests for
SLAP lesions, but the accuracy of the test was
reduced when performed by investigators other than
the originator of the test.
Tests for Acromioclavicular Joint Pathology
Scarf Test / Cross Arm Adduction Stress Test
This test is performed by passively adducting the
arm across the body while the shoulder is flexed to
90° [21,22]. Pain is suggestive of acromioclavicular
joint pathology. See Evidence Box 2 for a
comparison of the tests described below.
Active Compression Test (O’Brien Test)
This test can be used to differentiate
acromioclavicular and superior labral pathology. It is
conducted by actively flexing the arm to 90° with the
elbow fully extended [23]. The arm is then adducted
10-15° medial to the sagittal plane and then
internally rotated until the thumb is directed
downwards. The examiner then applies a downward
force to the arm. The arm is then fully supinated
while in the same position, and then force is again
applied. A positive result is pain experienced on the
first manoeuvre which is absent in full supination.
Pain over the anterior shoulder or ‘clicking’ in the
glenohumeral joint suggests superior labral
pathology while pain localised to the AC joint was
described as being diagnostic of AC joint pathology.
Acknowledgements
The authors would like to thank Jo Hunter and
Professor Glasziou for their invaluable help with the
literature review and evidence based review for the
article. Thanks to Mr. Shahane for his advice and
comments.
Conflicts of Interest
None declared.
Tests for Hyperlaxity
Beighton’s Hyperlaxity Score
If any of the above tests suggest joint laxity, further
testing for Generalised Joint Laxity (GJL) should be
considered. One scoring system is the Beighton
Score. This index involves examination of extension
of the fifth finger, thumb to forearm opposition with
the wrist flexed, elbow extension, knee extension
and flexion of the trunk and hip. Using a grading
system, an overall score with a maximum of 9 points
is produced. A score of 5 and above suggests GJL.
One study [17] found that the intrarater and interrater
reliability of the Beighton Score to have Spearman
Rho values of 0.86 and 0.87 respectively.
54 References
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Sports Medicine Update. A review of the special
tests associated with shoulder examination: Part II:
Laxity, instability and superior labral anterior and
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[14] http://www.shoulderdoc.co.uk/article.asp?
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of the subscapularis tendon. J Bone Joint Surg
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[8] Hegedus EJ, Goode A, Campbell S, Morin A,
Tamaddoni M, Moorman CT, Cook C. Physical
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review with meta-analysis of individual tests. Br J
Sports Med 2008;42:80-92
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Havva C, Tüzün F. Diagnostic values of clinical
diagnostic tests in subacromial impingement
syndrome. Ann Rheu Dis 2000; 59: 44-47
[10] Hawkins RJ, Kennedy JC. Impingement
Syndrome in athletes. Surg 2000; 9: 263-267
[11] Holtby R, Razmjou H. Validity of the
supraspinatus test as a single clinical test in
diagnosing patients with rotator cuff pathology. J
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[12] Gerber C, Hersche O, Farron A. Isolated
rupture of the subscapularis tendon. J Bone Joint
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[17] Boyle KL, Witt P, Riegger-Krugh C. Intrarater
and Interrater Reliability of the Beighton and Horan
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55 In a recent meta-analysis [8] it was shown that the Supraspinatus test had a sensitivity and specificity of 25-44%
and 67-90% respectively. While having a low sensitivity, the high specificity of this test makes it useful to confirm
the diagnosis of impingement. The Neer Impingement sign and the Hawkins-Kennedy test were not found to be
diagnostically useful as both had pooled Diagnostic Odds Ratios (DORs) around 1 with confidence intervals
including 1. One paper however [6] suggests that the Supraspinatus test may only significantly increase the posttest probability if the patient has a major rotator cuff tear, and may contribute little in diagnosis of mild pathology.
An additional test that might add further diagnostic weight, is the injection of 1% 10ml of lignocaine (lidocaine) into
the subacromial region (Neer’s Test). In patients with subacromial impingement, this quickly relieves pain on
active and passive motion and restores nearly complete range of motion. It should be noted however, that other
conditions, such as calcific tendonitis, and calcific subacromial bursitis, present in a similar way to impingement,
and are also relieved by lignocaine injection [9].
Evidence Box 1 Examination of suspected impingement syndrome.
No meta-analyses were found to compare the Active Compression Test and the Cross Arm Adduction Stress test.
One study [8] attempted to combine evidence available. Sensitivities and specificities for the Active Compression
test ranged from 16% to 93% and 90% to 96%. Sensitivities and specificities for the Cross Arm Adduction Stress
test were found to be 77% and 79% respectively [19]. Further analysis of these studies led authors to conclude that
the Active Compression test had the highest specificity of any special test to evaluate AC joint pathology and was
virtually diagnostic if positive. As it has a variable sensitivity through the literature, they recommended using
palpation of the acromioclavicular joint as a screening tool. Pain on palpation alone has a high sensitivity of 96%
but a low specificity of just 10%. Incorporating this data into practice, pain on palpation of the AC joint could be
used as a screening tool and then the Active Compression test could be used as a confirmatory test.
Evidence Box 2 Tests for AC joint pathology.
56